Healthcare Provider Details

I. General information

NPI: 1326278110
Provider Name (Legal Business Name): BRENT STEPHENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E NASA BLVD
MELBOURNE FL
32901-1950
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-361-5626
  • Fax: 321-723-9176
Mailing address:
  • Phone: 321-361-5626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberME119690
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME119690
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: